High School Retreat 2026
April 17th - 19th
Student's Full Name
*
First Name
Last Name
Student's Grade
*
9
10
11
12
Student's Gender
*
Male
Female
Parent's Name
*
First Name
Last Name
E-mail
*
Phone Number
*
Format: (000) 000-0000.
Family Doctor
*
Doctor's Phone Number
*
Format: (000) 000-0000.
Medical Insurance Co & Policy Number
*
Please list any special dietary needs or restrictions, medical allergies, problems, or other pertinent information
*
Please list any medication (s) being taken. (If there is medication you would like us to administer there will be a form at check-in to fill out with instructions.)
*
I, the undersigned parent or guardian of a minor, do hereby give an adult sponsor(s) in attendance with the group of River Oak Church, Chesapeake, Virginia, the authority to secure any necessary medical treatment for my son/daughter in the event of an emergency due to sickness or accident at any scheduled activity or travel to and from such activity. I understand that, in the event medical treatment is required, every effort will be made to contact my family doctor and/or me. However, if neither can be reached or the situation demands immediate attention, I give my permission to sponsor(s) to secure the services of a licensed physician to provide the care necessary for my child’s well being. I do hereby release sponsors of River Oak Church from any and all claims, demands, actions or cause of action arising out of any damage or injury while participating in any youth activity.
*
I understand and accept these terms
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Student Retreat Registration (includes housing, all meals & all activities)
$
125.00
Total
$
0.00
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